Inflatable Penile Prosthesis Reservoir Research Articles

Iatrogenic injuries to reservoirs of inflatable penile prosthesis during urologic surgery: a scoping review and case report.

First-line treatment options for patients with erectile dysfunction whose medical management has failed include the inflatable penile prosthesis (IPP). Many patients with an IPP require subsequent urologic surgery, during which the reservoir of the IPP can be injured. This review aims to present a summary of current literature related to iatrogenic injuries to the IPP sustained during urologic surgery. Two reviewers independently performed a systematic search on PubMed using standardized search terms to identify pertinent articles. After preliminary review, relevant studies were analyzed to identify the presence of perioperative complications resulting in IPP reservoir injury. Results were categorized by surgical procedures. Among 13 articles included, all were based on urologic surgery. Four studies identified IPP reservoir injury as a result of surgical injury. Of these, injuries occurred during radical prostatectomy (n = 3) and prostatic urethral lift surgery (UroLift, n = 1). Most radical prostatectomy studies without IPP reservoir injuries also described intentional surgical techniques that were employed to prevent reservoir damage, including modulation of reservoir inflation-deflation (n = 3), temporary reservoir repositioning (n = 1), or reservoir capsule dissection to improve visualization (n = 1). Findings from an additional novel case report on IPP injury during a UroLift procedure are presented in this review. Approximately one-third of studies identified intraoperative IPP reservoir injury as a significant complication of urologic surgery, particularly during radical prostatectomy. Novel case report findings also contribute the only other case of IPP reservoir damage sustained from delivery of UroLift implants. Findings are used to create a standardized surgical checklist that guides perioperative planning measures prior to pursuing surgery in adjacent spaces.

(025) Laparoscopic Assisted Reservoir Removal of an Infected Inflatable Penile Prosthesis in a Patient with Ipsilateral Inguinal Hernia Mesh Implant

Abstract Introduction Infection is a devastating complication of penile prosthesis implantation ranging from 0.33 to 11.4%. 1 Although a salvage procedure is an option in case of infection, the rule of thumb is to remove all device components. 2 Special considerations and pre-operative planning are essential for better outcome in the management of such condition. We are presenting a video case presentation demonstrating the use of laparoscopic assisted approach to aid in the extraction of the reservoir of an infected penile prosthesis from a patient who had ipsilateral inguinal hernia mesh implant Objective To demonstrate the feasibility and efficacy laparoscopic assisted approach in the removal of difficult to extract inflatable penile prosthesis (IPP) reservoir. Methods A 72-year-old gentleman with past medical history of Diabetes and hypertension presented to our clinic 3 weeks after an IPP insertion that was done in another center. He was complaining of right inguinal bulge and scrotal pain. The bulge developed suddenly without any preceding event. Examination confirmed a prosthesis reservoir herniation in to the right groin. Plan CT abdomen& pelvis confirmed the diagnosis. In three days, the herniated reservoir was managed by inguinal exploration, repositioning of the same reservoir in the right Retzius space and posterior inguinal canal wall repair using a mesh. The patient was discharged on post-operative day 1 in a stable condition, but unfortunately, he developed persistent scrotal pain that progressed into an overt scrotal infection over the early follow up period. During the examination, a scrotal collection was observed, swap was taken from the draining pus and results showed moderate growth of pseudomonas aeruginosa. On the other hand, the inguinal scar showed good healing with no tenderness, indicating the presence of an intact and non-infected inguinal mesh. Therefore, the decision was made to remove all components of the prosthesis without removing the mesh. Considering the anticipated challenges associated with removing the reservoir of the IPP through a scrotal approach, a decision was made to incorporate an additional laparoscopic-assisted abdominal approach for reservoir removal. Results Removal of the IPP cylinders and pump was performed through a scrotal incision, then a laparoscopic assisted abdominal approach was used successfully to remove the reservoir. After the IPP explant procedure, patient had an uneventful smooth recovery at the two and four weeks follow up visits, he was advised to use Vacuum erection device (VED) to alleviate possible penile fibrosis/shortening. A penile prosthesis reimplantation procedure was planned in a 6 months period Conclusions Laparoscopic assisted approach for penile prosthesis reservoir extraction is a feasible and safe technique that can be used in anticipated cases of difficult reservoir extraction. Pre-operative assessment, planning and counselling are crucial in obtaining a favorable outcome in such complex cases. Disclosure No.

(022) Penile Implant Reservoir Placement: The Current Utilized Various Techniques and the Associated Outcome: Systematic Review and Meta-Analysis

Abstract Introduction Many innovations in the field of inflatable penile prosthesis (IPP) has been emerged. Since the introduction of the IPP, reservoir positioning in the space of Retzius (SOR) was considered the classical approach that had been utilized for many years. However, in certain group of patients, reservoir insertion in such space might be difficult or even risky. As a result, many alternatives for the reservoir placement outside the SOR has emerged with the intent of safe and reliable reservoir placement. Objective To conduct a systematic review for the studies evaluating the outcomes of different techniques used for IPP reservoir placement to look for possible superiority of any approach over others. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed and Google scholar were used to look for articles published up to January 2023. Original articles reporting different techniques for IPP reservoir placement and evaluating the associated outcomes were included. Data regarding study design, sample size, approach of reservoir placement, surgical technique, device type and reported outcomes (infection rate, bladder/bowel/vascular injury, reservoir herniation, mechanical failure, auto-inflation, reservoir palpability and patients’ satisfaction) were collected. Pooled proportion was calculated and included in the meta-analysis. The Newcastle-Ottawa scale was used for assessing the quality of the studies. Results A total of 23 articles meeting the inclusion criteria, all were retrospective reviews. 11 compared more than one technique for reservoir placement whereas 12 described a single technique. In total, techniques for 6 main different reservoir locations has been reported, including SOR (7 studies), submuscular/subrectus (6 studies), Lateral retroperitoneal (1 study), subcutaneous (1 study), sub external oblique (1 study) and intraperitoneal (1 study). Another 7 modifications have been described for the SOR technique (traditional SOR, accessing SOR using blunt scissor in post-prostatectomy patients, accessing SOR using blunt scissor in virgin cases, dilating SOR using catheter balloon, accessing SOR under direct vision, accessing SOR through external oblique fascia incision, and the addition of The Tubing Hitch&Lasso, Intussusception Anchor technique (THALIA)). Another 6 modifications for the submuscular/subrectus approach have been described (posterior to transversalis fascia (PTF), anterior to transversalis fascia (ATF), high submuscular, subrectus using counter incision, subrectus with the addition of THALIA, low submuscular with trans-fascial-fixation (TFF)). None of the studies have proven the superiority of one technique over others, with most of the techniques has comparable intra-operative and post-operative outcomes (table 1). The addition of anchoring step (THALIA or TFF) resulted in neglected risk of reservoir herniation, however, related studies has small sample size with no comparison groups. Meta-analysis for the studies of SOR (n=7) and submuscular/subrectus (n=6) groups showed a statistically significant difference only in the herniation rates (figure 1). 10 studies were of strong quality (8 stars) while the remaining 13 studies were of poor quality. Conclusions Modest evidence suggests a comparable favorable outcome of various approaches used for IPP reservoir placement. The lack of enough prospective trials, short term follow up, and diversity in the techniques prescribed prevent the ability to build strong evidence. For the purpose of supporting the superiority of any technique, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

(194) Midline Reservoir Placement of Infrapubic Inflatable Penile Prosthesis: A Step-by-Step Surgical Technique

Abstract Introduction Various alternative placements of inflatable penile prosthesis (IPP) reservoirs have been previously documented, differing from the traditional retroperitoneal placement in the Space of Retzius. Pelvic trauma, history of surgery in the pelvic region, and atypical anatomy can necessitate an alternative location for implantation of the IPP reservoir. The midline placement of the IPP reservoir provides numerous advantages in outcomes, patient experience, and versatility of implantation. This video demonstrates the surgical procedure for midline placement of the IPP reservoir. Objective We outline a surgical technique to place the IPP reservoir in an alternative midline location. Methods The patient was instructed to void his bladder prior to the procedure to circumvent Foley catheter insertion. A 2.5 cm-wide horizontal incision was made 2 finger widths cranially to the dorsal aspect of the base of the penis. The surgeon’s index finger was used for blunt dissection along the linea alba above the pubic tubercles. A tonsil clamp is used to pierce the rectus fascia at the midline, below the arcuate line, to leave a defect just wide enough to accommodate a 70 mm nasal speculum. The surgeon’s finger is used to assess the space to determine if a 9/10 mm Hegar dilator is necessary to expand the avascular space by sweeping it parallel to the fascia. The speculum is inserted and positioned with the blades pointed cranially parallel to the facial axis and the handles pointed superiorly. The reservoir is prepared and delivered into this space using a metal pediatric Yankauer suction tip through the open blades of the nasal speculum. A syringe filled with saline solution is connected to the reservoir tubing, and the fluid is transferred completely to the reservoir and the tubing is clamped. The tubes originating from the reservoir and implant cylinders are both clamped, trimmed to length, and connected to each other in a watertight fashion to permit the bidirectional flow of saline solution. Proper IPP cylinder inflation is tested prior to closing the incision. Results The reservoir is thus safely deployed cranially to the pubic bone and avoids interfering with the urinary bladder. No complications were observed in this patient, and he was discharged on the same day. Conclusions The midline surgical placement of the reservoir during the infrapubic implantation of an inflatable penile prosthesis is a safe and effective alternative placement for patients with prior pelvic surgery, injuries, or atypical pelvic anatomy. Patients with compromised pelvic, abdominal, or inguinal regions due to hernia repair, patulous inguinal rings, or dense lateral pelvic scarring stand to benefit the most from this reservoir placement. This procedure outlines the surgical steps of midline reservoir placement for new IPP implantation or relocation during a revision procedure. Disclosure No.

(394) Penile Implant Reservoir Placement: The Current Utilized Various Techniques and the Associated Outcomes: Systematic Review and Meta-analysis

Abstract Introduction Many innovations in the field of inflatable penile prosthesis (IPP) has been emerged. Since the introduction of the IPP, reservoir positioning in the space of Retzius (SOR) was considered the classical approach that had been utilized for many years. However, in certain group of patients, reservoir insertion in such space might be difficult or even risky. As a result, many alternatives for the reservoir placement outside the SOR has emerged with the intent of safe and reliable reservoir placement. Objective To conduct a systematic review for the studies evaluating the outcomes of different techniques used for IPP reservoir placement to look for possible superiority of any approach over others. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed and Google scholar were used to look for articles published up to January 2023. Original articles reporting different techniques for IPP reservoir placement and evaluating the associated outcomes were included. Data regarding study design, sample size, approach of reservoir placement, surgical technique, device type and reported outcomes (infection rate, bladder/bowel/vascular injury, reservoir herniation, mechanical failure, auto-inflation, reservoir palpability and patients’ satisfaction) were collected. Pooled proportion was calculated and included in the meta-analysis. The Newcastle-Ottawa scale was used for assessing the quality of the studies. Results A total of 23 articles meeting the inclusion criteria, all were retrospective reviews. 11 compared more than one technique for reservoir placement whereas 12 described a single technique. In total, techniques for 6 main different reservoir locations has been reported, including SOR (7 studies), submuscular/subrectus (6 studies), Lateral retroperitoneal (1 study), subcutaneous (1 study), sub external oblique (1 study) and intraperitoneal (1 study). Another 7 modifications have been described for the SOR technique (traditional SOR, accessing SOR using blunt scissor in post-prostatectomy patients, accessing SOR using blunt scissor in virgin cases, dilating SOR using catheter balloon, accessing SOR under direct vision, accessing SOR through external oblique fascia incision, and the addition of The Tubing Hitch&Lasso, Intussusception Anchor technique (THALIA)). Another 6 modifications for the submuscular/subrectus approach have been described (posterior to transversalis fascia (PTF), anterior to transversalis fascia (ATF), high submuscular, subrectus using counter incision, subrectus with the addition of THALIA, low submuscular with trans-fascial-fixation (TFF)). None of the studies have proven the superiority of one technique over others, with most of the techniques has comparable intra-operative and post-operative outcomes (table 1). The addition of anchoring step (THALIA or TFF) resulted in neglected risk of reservoir herniation, however, related studies has small sample size with no comparison groups. Meta-analysis for the studies of SOR(n=7) and submuscular/subrectus(n=6) groups showed a statistically significant difference only in the herniation rates (figure 1). 10 studies were of strong quality (8 stars) while the remaining 13 studies were of poor quality. Conclusions Modest evidence suggests a comparable favorable outcome of various approaches used for IPP reservoir placement. The lack of enough prospective trials, short term follow up, and diversity in the techniques prescribed prevent the ability to build strong evidence. For the purpose of supporting the superiority of any technique, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

(471) The Transfacial Fixation of an Ectopic Low Submuscular Reservoir: A Novel Approach to Inflatable Penile Prosthesis Reservoir Placement

Abstract Introduction Ectopic reservoir placement has become a more routine practice among high-volume penile prosthesis implanters. In particular, the low submuscular approach has gained considerable popularity given its safe location away from structures of concern such as the iliac vein or bowel, which can frequently be in the proximity of reservoirs placed in the traditional Space of Retzius position in patients with prior pelvic procedures such as a radical prostatectomy. However, the low submuscular approach is not without its own risks, most notably, herniation of the reservoir to an unintended location. In order to maximize the benefits of submuscular reservoir placement and minimize risk for herniation, we describe a novel approach to low submuscular reservoir placement. Objective The objective of this study is to present outcomes data on inflatable penile prosthesis patients who underwent low submuscular (LSM) reservoir placement with transfascial fixation (TFF). Methods A retrospective review was conducted on patients who underwent an IPP placement using the LSM with TFF technique between June 2019 and March 2022 by a single, high-volume surgeon at a tertiary medical center. Preoperative patient characteristics were collected, and patients then conducted a telephone interview with a modified questionnaire to assess satisfaction with the IPP and reservoir concealment. Results A total of 34 patients underwent IPP surgery with low submuscular reservoir placement with TFF of which 29 completed the questionnaire (85.2%). The average age of patients was 68.3 years, and 61.5% of patients had undergone a radical prostatectomy. Overall satisfaction with the penile implant was 4.1 (out of 5). Eight patients (26%) were able to palpate the reservoir, and four patients (15.4%) were able to visualize the reservoir impression below the abdominal skin. However, overall satisfaction with reservoir concealment was 4.6 (out of 5) (Table 1). No surgical revisions were required and there were no surgical complications such as bowel obstruction, herniations, bladder erosion, or vascular injuries. Conclusions Low submuscular IPP reservoir placement with TFF is an alternative approach for reservoir placement with a high degree of patient satisfaction, decreased risk for reservoir herniation, and significant ease of placement compared to alternative methods in the literature. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific

(408) THALIA Technique Fixation of the IPP Reservoir

Abstract Introduction Inflatable penile prosthesis reservoir herniation or migration may occur with space of Retzius or submuscular placement. The dangers of high submuscular placement include bowel or bladder perforation (from blind instrument passage) and or bowel herniation (from unintentional peritoneal placement and stretching of small opening with reservoir filling). Even under direct vision submuscular placement, reservoirs can ultimately reside into the scrotum, retroperitoneum, and lateral abdominal wall. The Tubing, Hitch And Lasso, Intussusception Anchor (THALIA) technique was recently developed to prevent reservoir migration with placement either submuscularly or in the space of Retzius, but video of this technique has not been previously published. Objective To visually demonstrate the proper surgical technique of THALIA during IPP reservoir placement. Methods An IPP surgical candidate at high risk of complications should reservoir migration occur was identified. Video of THALIA technique performed during IPP surgery was recorded using an in-light overhead camera and a GoPro aseptically positioned on the lead surgeon. Results Successful demonstration of THALIA technique during IPP placement. Conclusions THALIA technique is a feasible option to aid prevention of penile implant reservoir herniation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

PD42-07 OUTCOMES RELATED TO INFLATABLE PENILE PROSTHESIS (IPP) RESERVOIR REMOVAL: A 7-YEAR MULTI-CENTER EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023PD42-07 OUTCOMES RELATED TO INFLATABLE PENILE PROSTHESIS (IPP) RESERVOIR REMOVAL: A 7-YEAR MULTI-CENTER EXPERIENCE Javier Piraino, Ian Madison, Matthew Ziegelmann, Run Wang, Tobias Kohler, Aram Loeb, Gerard Henry, Robert Cornell, Dylan Supak, Landon Trost, and Jonathan Clavell Javier PirainoJavier Piraino More articles by this author , Ian MadisonIan Madison More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , Run WangRun Wang More articles by this author , Tobias KohlerTobias Kohler More articles by this author , Aram LoebAram Loeb More articles by this author , Gerard HenryGerard Henry More articles by this author , Robert CornellRobert Cornell More articles by this author , Dylan SupakDylan Supak More articles by this author , Landon TrostLandon Trost More articles by this author , and Jonathan ClavellJonathan Clavell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 3-piece IPP is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the Space of Retzius (SOR) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition or infection. In revision cases without infection, reservoir removal is sometimes optional. We review outcomes and complications specifically related to reservoir removal from a large multi-institutional series. METHODS: We retrospectively reviewed databases at 6 institutions over 7 years. Patients with artificial urethral sphincter, urethral sling or Mini-jupette were excluded. Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected but only reservoir-related complications at surgery were included. Data were compared between SOR and AES cohorts to evaluate differences with χ2, with significance at p<0.05. RESULTS: Of 215 cases, there were 172 SOR (80%) and 43 AES (20%) reservoirs. Mean patient age was 65.3 years old. 131 (60.9%) procedures were due to malfunction, 49 (22.8%) were due to malposition of an IPP component, and 35 (16.3%) were secondary to infection. Among those retained (N=44, 20.5%), reasons included reuse, avoiding surrounding structure damage, unspecified, and difficult dissection. Among those removed (N=171), 15 (8.8%) required a counter-incision (6 in SOR and 9 in AES). χ2 to determine statistical difference between those removed from SOR and AES found a p=0.00059, indicating significant difference in the need for a counter-incision those groups. Complications included bladder perforation (N=1) in the SOR group, and an avulsion of the epigastric vessels requiring abdominal exploration (N=1) in the AES group. χ2 to determine statistical difference when comparing SOR and AES complications was p=0.365, indicating no significant difference between groups. CONCLUSIONS: Removal of an IPP reservoir remains safe with few complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counter incision to avoid injury to surrounding structures. Surgeons should obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first and largest multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1113 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Javier Piraino More articles by this author Ian Madison More articles by this author Matthew Ziegelmann More articles by this author Run Wang More articles by this author Tobias Kohler More articles by this author Aram Loeb More articles by this author Gerard Henry More articles by this author Robert Cornell More articles by this author Dylan Supak More articles by this author Landon Trost More articles by this author Jonathan Clavell More articles by this author Expand All Advertisement PDF downloadLoading ...

PD28-04 RESERVOIR DISTANCE FROM CRITICAL PELVIC STRUCTURES: RADIOGRAPHIC COMPARISON OF HIGH SUBMUSCULAR AND SPACE OF RETZIUS INFLATABLE PENILE PROSTHESIS PLACEMENT TECHNIQUES

You have accessJournal of UrologyCME1 May 2022PD28-04 RESERVOIR DISTANCE FROM CRITICAL PELVIC STRUCTURES: RADIOGRAPHIC COMPARISON OF HIGH SUBMUSCULAR AND SPACE OF RETZIUS INFLATABLE PENILE PROSTHESIS PLACEMENT TECHNIQUES Mehraban Kavoussi, Grayden Cook, Shaun Nordeck, Shervin Badkhshan, Samantha Nealon, Benjamin Dropkin, Gregory Joice, Sarah Sanders, Jeffrey Pruitt, Steven Hudak, and Allen Morey Mehraban KavoussiMehraban Kavoussi More articles by this author , Grayden CookGrayden Cook More articles by this author , Shaun NordeckShaun Nordeck More articles by this author , Shervin BadkhshanShervin Badkhshan More articles by this author , Samantha NealonSamantha Nealon More articles by this author , Benjamin DropkinBenjamin Dropkin More articles by this author , Gregory JoiceGregory Joice More articles by this author , Sarah SandersSarah Sanders More articles by this author , Jeffrey PruittJeffrey Pruitt More articles by this author , Steven HudakSteven Hudak More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002576.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) reservoir placement into the High Submuscular space (HSM) has been proposed as a strategy to prevent injury to organs adjacent to the Space of Retzius (SOR). SOR reservoir proximity to critical pelvic structures (CPS) has been previously established in a cadaver study. We sought to evaluate reservoir distance from CPS for SOR and HSM placements using cross-sectional imaging obtained following IPP insertion. METHODS: We retrospectively reviewed our institutional database and identified men who underwent IPP insertion between 2007 and 2020. Men who underwent subsequent cross-sectional abdominopelvic imaging following IPP insertion until October 2020 were included in this study. Two radiologists blinded to IPP surgical technique evaluated reservoir position to determine (a) mass effect on the bladder and iliac vessels and (b) the shortest distance between each of these structures and the reservoir. Men were grouped based on reservoir placement technique (SOR vs. HSM) as documented in the operative notes. Variables were analyzed using chi-squared, fisher’s exact, and student’s T-tests as indicated. RESULTS: Among 1010 IPP cases performed during the study interval, 139 (13.7%) met our inclusion criteria with imaging obtained an average of 827 ( + 785) days after IPP insertion. Oncologic follow-up (46%) was the most common indication for imaging. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%) or iliac vessels (34 vs. 4%) and were located roughly 5x further from the bladder (10 + 22 vs. 49 + 36 mm) and iliac vessels (5 + 9 vs. 23 + 26 mm, Table). CONCLUSIONS: This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement. These findings suggest a potential patient safety benefit via avoidance of bladder and iliac vessel related IPP reservoir complications. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e500 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mehraban Kavoussi More articles by this author Grayden Cook More articles by this author Shaun Nordeck More articles by this author Shervin Badkhshan More articles by this author Samantha Nealon More articles by this author Benjamin Dropkin More articles by this author Gregory Joice More articles by this author Sarah Sanders More articles by this author Jeffrey Pruitt More articles by this author Steven Hudak More articles by this author Allen Morey More articles by this author Expand All Advertisement PDF DownloadLoading ...

Single Port Robotic-Assisted Removal of an Eroded Inflatable Penile Prosthesis Reservoir and Repair of an Associated Bladder Fistula

ABSTRACT Introduction We present the case of a 73-year-old man who underwent single port robotic removal of a retained Inflatable Penile Prosthesis (IPP) reservoir with intravesical erosion and repair of an associated bladder fistula. The patient had a 3-piece IPP placed in 2014 for erectile dysfunction after radical prostatectomy for prostate cancer. He underwent device explant two years later for infection, at which time the IPP reservoir was “drained and retained”. He developed re-infection one year later and was again taken to the operating room; however, surgery was aborted due to vascular injuries. He presented to us for evaluation of dysuria and gross hematuria six years after initial IPP placement. Work-up with CT imaging and cystoscopy demonstrated intravesical erosion of the retained reservoir. Objective We aim to provide a step-by-step video demonstration of our technique for single port robotic-assisted removal of the eroded penile prosthesis reservoir and repair of an associated bladder fistula. Methods Procedures were performed using the da Vinci SP single port robotic system. The SP robot port was placed through a 3 cm incision superior to the umbilicus, and an additional 12 mm assistant port was placed in the Right Lower Quadrant (RLQ). The peritoneum was incised anteriorly lateral to the medial umbilical ligament, and the space of Retzius was developed by sharp and blunt dissection through densely adherent tissue planes. The pseudocapsule surrounding the eroded reservoir was incised, and the exposed reservoir was removed. Two fistulous tracts identified between the pseudocapsule and bladder were circumferentially excised, and the resultant bladder wall defect was repaired in a single layer with running 3-0 V-Loc suture. A drain was placed alongside the bladder repair and externalized through the RLQ assistant port. Results The patient tolerated these procedures well and without complications. He was admitted for routine postoperative observation overnight after surgery. On postoperative day one, the drain was removed, and the patient was discharged home with the Foley catheter remaining in place. At 2-week follow-up, the patient was recovering well and a cystogram was obtained showing no leaks, and the Foley catheter was removed. Conclusions This surgical case report demonstrates the feasibility and safety of performing removal of an eroded IPP reservoir through a minimally invasive approach with the da Vinci SP surgical system. The accompanying video provides a step-by-step demonstration of our technique. Disclosure No

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

ABSTRACT Introduction Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR), High Submuscular Space (HSM), or alternative locations via a transinguinal (TI) approach or a lower abdominal counter incision (CI). A cadaver study showed variability in reservoir location after TI-HSM placement (JSM: 2016 Sep;13(9):1425-1431). Objective We sought to evaluate reservoir location using cross-sectional imaging following contemporary IPP insertion. Methods We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion from 2007 to 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists blinded to reservoir placement technique evaluated cross-sectional imaging and categorized each reservoir location in relation to the abdominal wall musculature, transversalis fascia, and peritoneum. Statistical analysis was performed using Chi-squared and Fisher's exact tests. Results Among 561 men who underwent virgin IPP insertion during the 12 year study period, 114 had cross-sectional imaging subsequently obtained: 29 TI-SOR, 80 TI-HSM, and 5 CI-HSM (Table). TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (14 vs. 48%, p=0.001). TI-HSM reservoirs were less likely than TI-SOR to be located in the preperitoneal space (62 vs. 18%, p&amp;lt;0.001). Rates of retroperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups. Among all 561 patients (131 TI-SOR, 405 TI-HSM, and 25 CI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs. 2 vs. 0%, p = 0.24). Conclusions Roughly half of the TI-HSM reservoirs in this series appeared to be located posterior to the transversalis fascia on cross-sectional imaging. Although preperitoneal and retroperitoneal locations were common in both groups, reservoir related complications were rare. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Inflatable penile prosthesis reservoir placement—Are we ready for a paradigm change?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions.

Intravesical reservoir erosion as a late complication of a 3-piece inflatable penile prosthesis: ectopic placement in a high-subrectus space: a rare case report

Background: Inflatable penile prosthesis (IPP) is the mainstream treatment of refractory erectile dysfunction (ED). Usually, Space of Retzius (SOR) is the usual IPP reservoir placement space, however, more concerns regarding this space complication have emerged due to its anatomical proximity to some major structures. Intravesical reservoir erosion is the most common reported reservoir complication. Hematuria is the main presentation, sometimes, dysuria and urinary tract infection take place. We present a case of late intravesical reservoir erosion after 3 years of IPP implantation. Methods: Revision surgery was made including placement of AMS Conceal® reservoir in an ectopic high-subrectus space and anterior to transversalis fascia, contralaterally. Results: Recently, ectopic placement has gained popularity among implanters due to its safety and efficacy. Specifically, submuscular space placement, after inventing the lock-out valve to avoid undesirable auto-inflation due to the high back-pressure. Conclusion: Ectopic placement utilizes more choices in cases like hostile pelvis for implanting a 3-piece IPP instead of a malleable prosthesis. Ectopic placement is safe and highly acceptable between high-volume implanters, which may prime a new era of reservoir placement.

Distance From Critical Pelvic Structures: Radiographic Comparison of High Submuscular and Space of Retzius IPP Reservoir Placement Techniques

ObjectiveTo evaluate the distance from critical pelvic structures (CPS, defined as bladder and iliac vessels) among inflatable penile prosthesis (IPP) reservoirs placed into the space of Retzius (SOR) and high submuscular (HSM) locations using cross-sectional imaging. IPP reservoir placement into the HSM location has been proposed as a strategy to prevent injury due to greater distance from CPS. MethodsOur institutional database was retrospectively reviewed to identify men who underwent IPP insertion between 2007 and 2020 and had available cross-sectional abdominopelvic imaging after the time of surgery. Patients were grouped based on reservoir placement technique (SOR vs. HSM). Staff radiologists blinded to placement technique evaluated reservoir position to determine the shortest distance between CPS and the reservoir and if a mass effect was present on CPS. Variables were analyzed using chi-squared, Fisher's exact, and student's T-tests as indicated. ResultsAmong 1,010 IPP cases performed during the study interval, 139 (13%) were imaged. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%, P = <.01) or iliac vessels (34 vs. 4%, P = <.01) and were located roughly 5 times further from the bladder (10 ± 22 vs. 49 ± 36 mm, P = <.01) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, P = <.01). ConclusionThis study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement. To evaluate reservoir location using cross-sectional imaging following IPP insertion. We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests. Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability. Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort. The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts. This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature. Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;18:2039-2044.

State of the Reservoir: Current Concepts of Penile Implant Reservoir Placement and Potential Complications.

To discuss mechanical and surgical innovations in inflatable penile prosthesis (IPP) surgery and their implications on reservoir placement and patient outcomes. The past decade has seen a new emphasis on optimizing outcomes and minimizing complications associated with IPP reservoirs. Innovations in device design have accordingly yielded safer, more durable IPP outcomes over the past four decades. Modifications in surgical approach for reservoir placement abound for both traditional space of Retzius and ectopic reservoir placement techniques. Surgical and medical history, patient anatomy, and patient preference should all be considered when choosing approach for IPP reservoir placement. Prosthetic urologists should be proficient in multiple approaches to provide the best care to their patients.

The Tubing, Hitch and Lasso, Intussusception Anchor (THALIA) Technique: A Novel Approach to Fixate the Penile Implant Reservoir

BackgroundPenile implant reservoir herniation or migration after inflatable penile prosthesis (IPP) placement may occur with standard or submuscular placement. Additionally, fixating the tubing in patients with retained reservoirs may be helpful for future prosthetic surgeons. AimWe describe a novel technique to fixate IPP reservoirs in the preferred position. MethodsWe present our preferred technique to fixate IPP reservoirs to prevent migration or herniation. OutcomesWe evaluated our success in preventing reservoir herniation or migration. Results35 cases successfully underwent our new technique. 30 cases involved reservoirs that were thought to be at a high risk for migration. 5 cases were performed in non-infected retained reservoir scenarios where a reasonable attempt at removal either failed or was considered high risk. No immediate reservoir or infectious complications occurred. Mean follow-up was 5 months. The technique extended the case time by 5–10 minutes. ConclusionOur novel technique is feasible, and although further follow-up and power are needed, fixating the pump tubing may reduce reservoir complications.Yang D, Heslop D, Houlihan M, et al. The Tubing, Hitch and Lasso, Intussusception Anchor (THALIA) Technique: A Novel Approach to Fixate the Penile Implant Reservoir. J Sex Med 2021;18:224–229.

Explantation of High Submuscular Reservoirs: Safety and Practical Considerations

BackgroundOver the past decade, high submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs has emerged as a viable alternative to space of Retzius (SOR) placement; however, data comparing the feasibility and complications of HSM vs SOR reservoir removal do not presently exist. AimTo present a comparison of the safety, feasibility, and ease of removal of HSM vs SOR reservoirs in a tertiary care, university-based, high-volume prosthetic urology practice. MethodsData were retrospectively collected on patients who underwent IPP reservoir removal between January 2011 and June 2020. Cases were separated into 2 cohorts based on reservoir location. Statistical analysis was performed using Fisher's exact and Chi-squared tests for categorical variables and Student's t-test for continuous variables. Timing from IPP insertion to explant was compared between the HSM and SOR groups using the Mann-Whitney U test. OutcomesTime from IPP insertion to explant, operative time, intraoperative and postoperative complications, and need for a counter incision were compared between the HSM and SOR groups. ResultsBetween January 2011 and June 2020, 106 (73 HSM, 33 SOR) patients underwent IPP removal or replacement by a single surgeon at our institution. Average time from IPP insertion to removal was 43.6 months (24.2 HSM, 52.7 SOR, P = .07)—reservoir removal occurred at the time of device explant in 70 of 106 (66%) cases. More HSM reservoirs were explanted at the time of IPP removal compared with the SOR cohort (54 of 73, 74% HSM vs 16 of 33, 48.5% SOR, P = .01). Similar rates of complications were noted between the HSM and SOR groups (1.9% vs 6.3%, P = .35). There was no significant difference in need for counter incision between the 2 groups (24 [42%] HSM vs 4 [25%] SOR, P = .16) or in average operative times (76.5 ± 38.3 minutes HSM vs 68.1 ± 34.3 minutes SOR, P = .52). Clinical ImplicationsOur experience with explanting HSM reservoirs supports the safety and ease of their removal. Strengths and LimitationsAlthough the absolute cohort size is relatively low, this study reflects one of the largest single-institution experiences examining penile implant reservoir removal. In addition, reservoir location was not randomized but was instead determined by which patients presented with complications necessitating reservoir removal during the study period. ConclusionsHSM reservoir removal has comparable perioperative complication rates and operative times when compared with SOR reservoir removal.Kavoussi M, Bhanvadia RR, VanDyke ME, et al. Explantation of High Submuscular Reservoirs: Safety and Practical Considerations. J Sex Med 2020;17:2488–2494.

Avoiding deep pelvic complications using a 'Five-Step' technique for high submuscular placement of inflatable penile prosthesis reservoirs.

To compare our extended experience with high submuscular (HSM) reservoir placement to traditional space of Retzius (SOR) placement and to present our current, refined 'Five-Step' technique (FST) for HSM placement. Data were retrospectively collected on patients undergoing inflatable penile prosthesis (IPP) placement between January 2009 and June 2019. Re-operative cases were excluded. Reservoir-related complications and subsequent revisions were compared between SOR (2009-2012) and HSM reservoir groups (2012-2019). HSM patients were subdivided into two cohorts: 'Initial Technique' (2012-2014) and FST (2014-2019). The refined FST protocol was developed in 2014 to optimise outcomes and includes the following steps: (i) Position and Access; (ii) Develop Lower HSM Pocket; (iii) Develop Upper HSM Pocket; (iv) Reservoir Delivery (fill and fine-tune); (v) Confirm and Connect. Between January 2009 and June 2019, 733 total IPP procedures (586 HSM, 147 SOR) were performed by a single surgeon at our institution, 561 of which were virgin cases (430 HSM, 131 SOR) and included in this analysis. Overall, surgical revision was required in 10/430 (2.3%) HSM cases (one delayed bowel obstruction, nine herniations) and six of 131 (4.6%) SOR cases (one bladder erosion, two vascular injuries, and three herniations, P=0.22). When comparing the FST to the Initial Technique, we noted a significant decrease in complications requiring surgical revision (P=0.01). Among 133 cases performed with the Initial Technique, seven (5.3%) required surgical revision (one bowel obstruction after placement into the peritoneal cavity, six herniations). Among 297 FST cases, three (1.0%) required revision, all due to herniation. HSM placement of IPP reservoirs is a safe alternative to traditional SOR placement. Major deep pelvic reservoir complications were minimised using our current refined FST.

MP39-12 EXTENDED EXPERIENCE WITH HIGH SUBMUSCULAR PLACEMENT OF INFLATABLE PENILE PROSTHESIS RESERVOIRS

INTRODUCTION AND OBJECTIVE:High submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs is a promising new FDA approved alternative to traditional space of Retzius (SOR) reserv...